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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot size PM Owner's Name Earl Cathgart Address 2294 E . Waterloo Rd . Phone 466-0414 Contractor Williams P 1 U m b 1 n*dress 2 3 6 0 N . W1 1 S o n W a VLicense No.Z82223—Phone—466-4nn4 OF WELL/PUMP: _ . NEW WELL.O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: ANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A --CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of avation Dia. of Well Casing El Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal pe of Grout F-1Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction tC7"""Well'Diameter'' _ Sealing Material Stop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION-C] REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is til '1%. �1 available within 200 feet.) Installation will serve: Residence_ Commercial Other i. Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: ' - - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENTfPL"T.'0 '"`��`� _-"- Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size tFILTE:R BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home:owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 1 The applicant not call for all re uire inspections. Complete drawing on reverse side. ^ � _`- Signed X y� Title: �.btiti a�7 Date: FOR DEP RTMENT USE ONLY Application Accepted by to f 5 Area q Pit or Grout Inspection,by Date FinaUfn pection by Cal/ Date Additional Comments: a L, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I CK 0 FREE INFO S AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. i + EH 13-241REV.1iH51 EH 1 4-29